First Name * Surname * Address * Phone number * Mobile * Date of Birth * Email address * Doctors name * Doctor’s phone number * Emergency contact name * Emergency contact number * Confidential Health Questionnaire If you are between the ages of 16 and 69, the PAR-Q will tell you if you should check with your doctor before you significantly change your physical activity patterns. If you are over 69 years of age and are not used to * Yes No Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? * Yes No Do you feel pain in your chest when you do physical activity? * Yes No In the past month, have you had a chest pain when you were not doing physical activity? * Yes No Do you lose your balance because of dizziness or do you ever lose consciousness? * Yes No Do you have a bone or joint problem (for example back, knee, hip, shoulder) that could be made worse by a change in your physical activity? * Yes No Is your doctor currently prescribing medication for your blood pressure or a heart condition? * Yes No Do you know of any other reason why you should not do physical activity? * Yes No If you have answered YES to anything, please comment: YES to one or more questions: you should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health. ‘Having answered YES to one or more of the above, I have sought medical advice and my GP/Medical Practitioner has agreed that I may exercise.’ Date of signature NO to all questions: It should be reasonably safe for you to participate in physical activity, gradually building up from your current ability level. Please continue with the questionnaire. Have you or do you suffer from any of the following: (Please tick & give details where appropriate) Yes No Asthma * Yes No High Blood Pressure * Yes No Low Blood Pressure * Yes No Arthritis * Yes No Dizziness/fainting * Yes No Heart Disease * Yes No Are you/recently been pregnant * Yes No Epilepsy * Yes No Diabetes Type I / II * Yes No Joint Pain * Yes No Anything else (give details below) * Yes No Details: Have you ever had surgery? * Yes No Have you ever broken any bones? * Yes No Do you suffer from back pain? * Yes No Do you have tension or soreness in a specific area? * Yes No Do you experience numbness, tingling or stabbing pains anywhere? * Yes No Details Have you had any of the following: physiotherapy, osteopathy, chiropractic, massage therapy, other? Please give details: * Please list any medications you are currently taking ‘I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury. I will work at an appropriate level for myself and stop if Agree Your name * Your signature * Date * How did you find out about these classes?